Provider Demographics
NPI:1295713055
Name:GONZALEZ DIEZ, MARIANO E (MD)
Entity type:Individual
Prefix:MR
First Name:MARIANO
Middle Name:E
Last Name:GONZALEZ DIEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9945
Mailing Address - Street 2:COTTO STATION
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613-9945
Mailing Address - Country:US
Mailing Address - Phone:787-880-5031
Mailing Address - Fax:787-879-4461
Practice Address - Street 1:AVE MIRAMAR #540
Practice Address - Street 2:SUITE #3
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-880-5031
Practice Address - Fax:787-879-4461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8699207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E20542Medicare UPIN
81651Medicare ID - Type Unspecified